- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.49 / $1,235.88 / $1,272.77
| Professional | | $909.49 | $1,235.88 | $1,272.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.60 / $1,291.22 / $1,344.24
| Professional | | $1,143.60 | $1,291.22 | $1,344.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.88 / $396.70 / $2,077.50
| Professional | | $148.88 | $396.70 | $2,077.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.66 / $210.66 / $210.66
| Professional | | $210.66 | $210.66 | $210.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.07 / $886.51 / $1,355.25
| Professional | | $709.07 | $886.51 | $1,355.25 |